Medication Errors Harm 1.5M U.S. Residents Annually, New Institute Of Medicine Report Says
On average, a patient hospitalized in the U.S. will experience at least one medication error per day (Neergaard, AP/San Francisco Chronicle, 7/21);
Each year, medication errors cause at least 400,000 preventable injuries and deaths in hospitals, more than 800,000 in nursing homes and long-term care facilities, and more than 530,000 among Medicare beneficiaries treated in outpatient settings (Maugh, Los Angeles Times, 7/21);
Confusing drug labels and packaging cause one-quarter to one-third of all medication errors and contribute to 30% of all medication-error deaths (Wang, Wall Street Journal, 7/21);
More than half of patients do not take medications exactly as prescribed (Weise, USA Today, 7/21);
Hospitals and long-term care facilities typically do not report medication errors to patients or their family members unless the errors result in injury or death; and
At least one-quarter of injuries caused by medication errors are clearly preventable.
The most common medication errors include nurses administering the wrong medications or wrong dose in a intravenous drip, physicians prescribing drugs that could cause dangerous interaction with patients' other medications and pharmacists dispensing 100-milligram tablets when 50-milligram tablets were prescribed, according to the report (Washington Post, 7/21). The report, the fourth in a series by IOM to examine medical errors, is a follow-up to a 1999 report that found as many as 98,000 deaths occur annually because of medical errors (Harris, New York Times, 7/21). The 1999 report found that 7,000 medical error deaths are the result of a medication mistake (Los Angeles Times, 7/21). Recommendations
The report calls on U.S. government agencies to take the lead in implementing steps to reduce medication errors and recommends deadlines for completing such steps. The report recommends the government spend $100 million annually to research the most useful and cost-effective ways to reduce medication errors (Wall Street Journal, 7/21). Panel Co-Chair J. Lyle Bootman, dean of the University of Arizona College of Pharmacy, said the research should focus on reducing errors in settings where medications are heavily used, including pediatric, psychiatric and long-term care facilities (Washington Post, 7/21). In addition, the report recommends that:
FDA and the Agency for Healthcare Research and Quality work with the pharmaceutical industry to address problems with drug labels and packaging by the end of 2007 and possibly implement standardized drug names and labels (Wall Street Journal, 7/21);
All health care providers by 2008 develop plans to transition to electronic prescribing systems (Washington Post, 7/21);
All health care providers by 2010 begin using electronic prescribing systems (USA Today, 7/21);
The National Library of Medicine create a central online database for consumers to find information on medications and work with FDA and CMS to consider creation of a nationwide telephone hotline for patients who cannot read printed information (Wall Street Journal, 7/21);
All health care providers report medication errors to patients and family members, regardless of whether harm occurred (Washington Post, 7/21);
Pharmaceutical companies disclose all clinical trial results and limit the practice of providing physicians with free samples of medications because the samples are poorly regulated (New York Times, 7/21);
Pharmaceutical companies package pills in blister packs in order to simplify identification and make it easier for consumers to remember if they took a dose (Washington Post, 7/21);
Patients maintain a list of all prescription and nonprescription treatments they take and review the document with their health care provider to ensure there are no potential drug interactions; and
Patients read, understand and abide by medication instructions (USA Today, 7/21).
Comments From Panelists
Bootman said, "Our recommendations boil down to ensuring that consumers are fully informed about how to take medications safely and achieve the desired results and that health care providers have the tools and data necessary to prescribe, dispense and administer drugs as safely as possible and to monitor for problems" (Carey, CQ HealthBeat, 7/20). Bootman said the "good news" is that many medication errors are preventable and have "cost-effective solutions" (Nesmith, Atlanta Journal-Constitution, 7/21). Panel member Kevin Johnson of the Vanderbilt University School of Medicine said, "We were initially quite surprised by the number of mistakes, but the more we heard, the more convinced we were that these are actually serious underestimates" (Los Angeles Times, 7/21). Panel member Albert Wu, a drug safety expert at Johns Hopkins University, said, "Everyone in the health care system has to wake up and take this more seriously" (Washington Post, 7/21). Wu said patients should ask their providers questions if they are "not sure of something," adding, "It may be a little bit of an annoyance to providers, but we will get used to it" (Los Angeles Times, 7/21). Panel member Charles Inlander, president of the People's Medical Society, said, "Everyone in the health care system knows this is a major problem, but there's been very little action, and it's generally remained on the back burner." He added, "With this report, we hope to give everyone involved good, hard information on how they can prevent medication errors and then create some pressure to have them implement it." More Comments
FDA said in a statement that the report "provides a much needed perspective on the frequency, severity and preventable nature of medication errors," adding that the recommendations "are supported by efforts already underway at FDA in the areas of medication error prevention, patient education and label comprehension." Cecil Wilson, board chair of the American Medical Association, said, "Physicians face a dizzying array of choices when trying to purchase" information technology systems, "while struggling with high costs, interoperability and ease of use" (Washington Post, 7/21). Alicia Mitchell, spokesperson for the American Hospital Association, said hospitals since 1999 have been "actively engaged in looking at using information technology to improve patient safety," adding that a recent AHA poll finds that 92% of its members plan to adopt electronic medical records. Arthur Levin, director of the Center for Medical Consumers and an author of the 1999 IOM report, said, "This country has not taken seriously the alarms we sounded in 1999. Why?" (New York Times, 7/21).
The report is available online. Broadcast Coverage
CBS' "Evening News": The segment includes comments from Wilson Pace, an IOM panel member and professor at the University of Colorado, and Robert Fakelmann, director of medication safety and clinical services at Hackensack University Medical Center (Kaledin, "Evening News," CBS, 7/20) The complete segment is available online in RealPlayer.
NBC's "Nightly News": The segment includes comments from Bootman; Bill Churchill, director of pharmacy services at Brigham and Women's Hospital; and Wu (Costello, "Nightly News," NBC, 7/20). The complete segment is available online on MSNBC Video.
NPR's "All Things Considered": The segment includes comments from Michael Cohen, a co-author of the report and president of the Institute for Safe Medication Practices; Jim Conway, a co-author of the report and former executive at Dana Farber Cancer Institute; Sylvia Bartel, chief pharmacist at Dana Farber; and Inlander (Knox, "All Things Considered," NPR, 7/20). The complete segment is available online in RealPlayer.
"Reprinted with permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.
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